Physicians counseling women faced with giving birth to extremely premature babies
may be offering inconsistent and sometimes misleading information, according to researchers at the Indiana University School of Medicine.
In a simulation study involving 15 neonatologists and 16 obstetricians, a scenario was created in which the physicians met with "standardized" patients portraying pregnant women with ruptured membranes at 23 weeks' gestation. The researchers recorded the sessions and tabulated the physicians' numerical risk estimates and other statements.
"The estimates provided by physicians varied substantially, and obstetricians and neonatologists used different terms to describe the chances of surviving without disability." said study author Brownsyne Tucker Edmonds, M.D., M.P.H., assistant professor of obstetrics and gynecology and a Robert Wood Johnson Foundation Harold Amos Medical Faculty Development Program scholar.
The results of the study were reported in the early online edition of the Journal of Maternal-Fetal and Neonatal Medicine.
The study evaluated physician counseling regarding periviable neonates -- those born between 22 to 25 weeks' gestational age, compared with a normal pregnancy of 40 weeks. As many as half of such neonates do not survive, and about two-thirds of those who do survive suffer moderate to severe neurological disability, the study authors noted. Therefore physicians need to counsel families about the prognosis and help them make resuscitation decisions and delivery management plans.
Comparing the two specialties, 80 percent of the neonatologists provided numeric estimates of survival, while just over a third of the obstetricians did, frequently deferring a discussion of "exact numbers" to neonatologists. However, the neonatologists' estimates of survival chances ranged from 3 percent to 50 percent, and half of them provided more than one estimate in a single patient encounter.
Along with other numerical inconsistencies, the researchers found "noteworthy" differences in the apparent meaning given by obstetricians to the term "intact" survival, which is understood by many practitioners to mean "without impairment." However, to neonatologists -- none of whom used that term in the study – it may mean the child is not classed as "moderate to severe" or "profoundly" impaired, the researchers said.
The researchers said they believe that the varying estimates given by neonatologists were due to the inherent difficulty in offering precise survival estimates as opposed to lack of knowledge.
“There’s just tremendous uncertainty surrounding outcomes for any given child,” Dr. Tucker Edmonds said.
Nonetheless, the researchers said, such differences are concerning and pose a threat to quality and patient-centered care.
"We need to develop better tools and training to improve the quality of communication to women and families in these situations," Dr. Tucker Edmonds said.
Additional researchers involved in the study were Fatima McKenzie, M.S., and Janet Panoch, M.A., of the Department of Obstetrics and Gynecology, IU School of Medicine; and Richard M. Frankel, Ph.D., of the Mary Margaret Walther Center for Research and Education in Palliative Care, IU Simon Cancer Center, Roudebush Veterans Affairs Medical Center and the Regenstrief Institute.
The research was supported by Grant Number KL2 TR000163 from the National Institutes of Health, National Center for Advancing Translational Sciences, Clinical and Translational Sciences Award and the Robert Wood Johnson Foundation’s Harold Amos Medical Faculty Development Program.
This story was originally published by the IU School of Medicine on Nov. 17, 2014.